Nursing

Perioperative Nursing Data Set (PNDS) PNDS Latest Update via UMLS 2011 Original Publication 1999 Created in 1993, PNDS is maintained by the Association of periOperative Registered Nurses (AORN) Board of Directors (Taulman & Latz, 2011). PNDS is a “standardized language that addresses the perioperative patient experience from pre-admission until discharge; and describes the nursing diagnoses, […]

Omaha System Omaha System Latest Update via UMLS 2005 Original Publication 1975 The Omaha System includes terminology and an implicit information model. In the 1970s, the Visiting Nurse Association (VNS) of Omaha revised its home health and public health client records to adopt a problem-oriented approach. This new approach, with the goal of providing a

Nursing Interventions Classification System (NIC) and Nursing Outcomes Classification (NOC) NIC and NOC Latest Update via UMLS NIC- 2008 NOC- 2008 Original Publications NIC- 1992 NOC- 1997 NIC and NOC were initially developed through funding from the National Institutes of Health by research teams at the University of Iowa. The Center for Nursing Classification and

NANDA International (NANDA-I) NANDA-I Latest version of terminology standard available through UMLS 2002 Original Publication 1973 Collaboration at the 1973 National Conference Group task force resulted in the creation of NANDA (North American Nursing Diagnosis Association) in 1982. In 2002, NANDA became NANDA International (NANDA-I) to reflect the worldwide use of the terminology. The initial

Logical Observation Identifiers Names and Codes (LOINC) LOINC Latest Update via UMLS 2017 Original Publication 1994 The Regenstrief Institute maintains LOINC as a comprehensive clinical terminology for identifying tests, measurements and observations. LOINC includes terms for laboratory test orders and results, clinical measures such as vital signs, standardized survey instruments and other patient observations. Comprised

Identifying Challenges and Opportunities within Standard Nursing Terminologies 6 communicate similar meaning across systems (Westra, Delaney, Konicek, & Keenan, Nursing standards to support the electronic health record., 2008). Table 1 below includes the 12 SNTs by category. Table 1. ANA-Recognized Standard Nursing Terminologies Interface Terminologies Minimum Data Sets 1. Clinical Care Classification (CCC) System 2.

Consolidated SNT timeline Currently, the ANA recognizes two minimum data sets, two reference terminologies and eight interface terminologies for facilitating documentation of nursing care and interoperability of nursing data between multiple concepts and nomenclatures within IT systems (ANA, ANA Recognized Terminologies that Support Nursing Practice, 2012). The definitions of each of these types of terminologies

Standard Nursing Terminologies: A Landscape Analysis MBL Technologies, Clinovations, Contract # GS35F0475X Task Order # HHSP2332015004726 May 15, 2017 Identifying Challenges and Opportunities within Standard Nursing Terminologies 2 Table of Contents I. Introduction …………………………………………………………………………………………. 4 II. Background ………………………………………………………………………………………….. 4 III. Landscape Analysis Approach ………………………………………………………………….. 6 IV. Summary of Background Data …………………………………………………………………. 7 V. Findings……………………………………………………………………………………………….. 8

What’s the future of data and technology? Eliminating duplication of effort will go a long way to simplifying and streamlining nursing workflow within EHRs. Patient care devices (such as cardiac monitors, vital sign monitors, and I.V. infusion pumps) can be linked with the EHR. Many of them are essentially mi- ni-computers that store and send

How do nursing practice and data inform each other? Nurses, who do most of the EHR documentation (in- cluding plans of care, physiological parameters, assess- ments, interventions, and progress evaluations) in hos- pitals, are critical to care integration and patient safety. Whether entered into flow sheets or as “smart phrases” or narratives, all data are